Health inspection·February 20, 2025

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents were treated with dignity and respect and were free from physical restraint use when 1 resident had a splint on one hand and a nonskid sock covering the other hand for 1 resident (Resident #116) of 2 residents observed for positioning and mobility. Residents Affected - Few Findings include: Review of the admission record documented that Resident #116 was admitted to the facility on [DATE], with medical diagnoses including hemiplegia [the complete loss of movement of one side of the body] and hemiparesis [weakness and partial loss of movement of one side of the body] following cerebral infarction affecting right dominant side [a stroke affecting the right side of the body],cognitive communication deficit[ difficulty communicating], and contracture, left hand [ a tightening of muscles and ligaments that prevents normal movement of the affected part]. During an observation on 02/17/2025 at 1:53 PM, Resident #116 was wearing a splint on her left hand and a non-skid sock on her right hand. During an observation on 2/1820/25 at 9:28 AM Resident #116 was observed lying in bed with her eyes closed. There was a splint on her left hand, and a non-skid sock on her right hand. During an observation on 2/18/2025 at 12:58 PM Resident #116 was dressed in street clothes, her hair had been combed. She had a splint on her left hand, and a non-skid sock on her right hand. During an observation on 2/1920/25 at 8:51 AM, Resident #116 could be heard from outside of her room calling out,hollering. Upon entering her room, she was observed lying in bed with her eyes open. She was wearing a blue sock on her right hand and a splint on her left hand. During an interview on 2/19/2025 at 8:50 AM, Staff C, Licensed Practical Nurse (LPN) stated, Her [Resident #116] daughter either requested the sock or approved it. During an interview on 2/19/25 at 9:53 AM, the Administrator stated, She [Resident #116] should not have a sock on her hand. Review of Resident #116's physician orders from 12/01/2024 through 2/17/2025 revealed no orders for gloves, mittens, or Geri-sleeves (sleeves used to protect the skin on arms and legs from damage caused by friction and shearing). Page 1 of 19 105652 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #116's Consent forms revealed no consent for gloves, mittens or any form of restrictive or restraining devices for her hand. Review of the policy and procedure, titled, Restorative - Physical Restraint Program, last reviewed of 12/10/2024, read, Policy: The facility will not impose the use of any physical restraint on any resident for discipline or convenience . Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the residents body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body . Devices that may meet the definition of physical restraints are leg or hand restraints, hand mitts . 105652 Page 2 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure accuracy of minimum data set assessments for 1 (Resident #4) of 6 residents reviewed for respiratory services and 1 (Resident #143) of 5 reviewed for unnecessary medications. Residents Affected - Few Findings include: 1)Resident #4 physician order dated 7/5/2024 read, Oxygen @ 3 L/Min (at 3 liters per minute) continuous inhalation via nc (nasal cannula) every shift for sob (shortness of breath). Review of Resident #4 Minimum Data Set (MDS) titled Quarterly dated 12/24/2024 read, Section O Special Treatments, Procedures and Programs: Oxygen therapy was coded No. Review of Resident #4 admission Record resident was admitted on [DATE] with diagnosis including but not limited to acute respiratory failure with hypoxia, heart failure, type 2 diabetes, and acute posthemorrhagic anemia. During an interview on 2/19/2025 at 3:40 PM with the Regional MDS Consultant stated, [Resident #4's MDS appears to need to be corrected. I will modify Section O and correct the oxygen section. 2)Review of Resident #143 no physician order for insulin. Review of Resident #143 Medication Administration Record (MAR) for the month of November 2024 there was no insulin administered for the month. Review of Resident #143 diagnosis did not include Diabetes Mellitus. Review of Resident #143 MDS titled Quarterly dated 11/25/2024 read, Section N-Medication documented resident received insulin injections for last 7 days. During an interview on 2/19/2025 at 3:42 PM with the Regional MDS Consultant stated, [Resident #143's MDS appears to need to be corrected, insulin was not administered. I will modify the section. We follow the RAI (Resident Assessment Instrument). 105652 Page 3 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #44) of 3 residents reviewed for urinary tract infections (UTI) , and for 1 resident (Resident #21) of 4 residents reviewed for mood and behaviors. Findings include: Review of Resident #21's medical record documented diagnoses that included depression. Review of Resident #21's physician progress note dated 1/31/2025 read, Chief Complaint: Depression, dementia and insomnia. Reason for Today's Encounter: Today, I saw the patient for medication management as patient has active psychiatric diagnosis, is on psych( psychiatric) meds(medications), is in the facility setting, and the last psychiatric visit was 4 or more weeks ago and as it was reported to me that patient is unstable requiring psychiatric assessment. History of Present Illness: This is a [AGE] year old patient with a past psychiatric history of depression, dementia and insomnia. Review of Resident #21's progress note dated 11/09/2024 read, resident refused shower for nurse and certified nursing aide. Resident began to get upset once staff was consistently kept encouraging him to do so. Resident refused x 3. Review of Resident #21's progress note dated 1/06/2025 read, Resident refused shower today. Review of Resident #21's progress note dated 1/09/2025 read, resident refused labs, MD(Medical Doctor) in facility and made aware, no new orders received. Review of Resident #21's care plan did not reveal a care plan focus related to a focus on potential of behavior related to diagnosis of depression or being unstable. During an interview conducted on 2/19/2025 at 7:45 AM the Director of Nursing (DON) stated The interdisciplinary team (IDT) should have initiated a care plan for [Resident #21's name] with a focus for behaviors, refusing care, or being on an anti-depressant with interventions and goals and this was not done. 2) Review of Resident #44's medical record documented diagnoses that included a diagnosis of urinary tract infection(UTI). Review of Resident #44's physician order dated 2/12/2025 read, Macrobid 100MG, give 1 capsule by mouth two times a day for UTI (urinary tract infection) for 7 days. Review of Resident #44's care plan did not show a care plan for a UTI or antibiotic therapy. During an interview on 2/18/2025 at 8:15 AM the Administrator stated , The IDT (interdisciplinary team) is responsible for identifying and care planning and failed to do so for [Resident #44's name]for a UTI (urinary tract infection) or for antibiotic therapy and the team should have done so. 105652 Page 4 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) On 2/18/2025 at 8:21 AM, Resident #456 was sitting semi reclined in her bed in her room. Resident #456 was holding a medication cup in her hand. There were 3 tablets and 1 capsule in the medication cup that Resident #456 was holding. There was no nurse in Resident #456's room. A nurse was standing outside of Resident #456's room at a medication cart attending to a computer screen. Residents Affected - Few During an interview on 2/18/2025 beginning at 8:21 AM, Resident #456 stated the tablets and the capsule in the medication cup were her medicine. She pointed at the capsule and stated this one is for my head. Review of Resident #456's care plan, date initiated 2/6/2025, failed to reveal documentation Resident #456 had been assessed as capable of self-administration of her medications. Review of Resident #456's medication administration records, dated 2/1/2025 through 2/28/2025, documented Resident #456 had been administered Metoprolol Succinate ER [Extended Release] 24 Hour 100 milligrams for hypertension; Meloxicam oral tablet 7.5 milligrams 1 tablet by mouth one time a day for muscle spasms; Lisinopril oral tablet 5 milligrams 1 tablet by mouth one time a day for hypertension; and Cephalexin capsule 500 milligrams 1 capsule three times a day for abscess on scalp for 10 days on 2/18/2025 at 9:00 AM. During interview on 2/19/2025 at 9:44 AM, Staff A, Registered Nurse, stated the nurse administering medications was supposed to watch residents swallow medications during medication administration. During interview on 2/19/2025 at 11:56 AM, the Director of Nursing stated her expectation was the nurse should stay in the resident's room until the resident had taken the administered medications. Based on interview and record review the facility failed to administer blood pressure medication following parameters for 2 (Resident #103 and 143) out of 8 residents reviewed for medication administration and failed to follow professional standards of practice during medication administration to 1 resident, Resident #456. Findings include: 1.) Review of Resident #103 physician order dated 9/7/2023 read, Metoprolol Tartrate Oral Tablet 25 MG (milligram) (Metoprolol Tartrate) Give 12.5 mg by mouth two times a day for hypertension hold for SBP<120 (systolic blood pressure less than 120). Review of Resident #103's Medication Administration Record (MAR) for the month of January 2025 documented Metoprolol Tartrate 12.5 mg was given at 0900 [9:00 AM] on 1/16/2025 with a systolic blood pressure (SBP) of 108, 1/18/2025 with a systolic blood pressure of 118, 1/19/2025 with a SBP of 115, 1/21/2025 with a SBP of 114, 1/30/2025 with a SBP of 118 and at 2100 [ 9:00 PM] on 1/5/2025 with a SBP of 113, 1/15/2025 with a SBP of 117, 1/19/2025 with a SBP of110, 1/23/2024 with a SBP of 118, 1/28/2025 with a SBP of 110 and on 1/29/2025 with a SBP of 113. Review of Resident #103's Medication Administration Record (MAR) for the month of February 2025 documented Metoprolol Tartrate 12.5 mg was given at 0900 [9:00 AM] 2/6/2025 with a SBP of 116, 2/14/2025 with a SBP of 111, 2/17/2025 with a SBP of 114, 2/18/2025 with a SBP of 116, on 2/19/2025 with a 105652 Page 5 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few SBP of 114 and at 2100 on 2/4/2025 with a SBP of 118, 2/5/2025 with a SBP of 112, 2/12/2025 with a SBP of 110, 2/15/2025 with a SBP 118, 2/16/2025 with a SBP of 112, 2/17/2025 with a SBP of 116 and on 2/18/2025 with a SBP of 114. Review of Resident #103 admission record resident was admitted on [DATE] with diagnosis including but not limited to atrial fibrillation, essential hypertension, fatigue, dysuria. During an interview on 2/19/2025 at 10:40 AM with the Director of Nursing stated, [Resident #103's name] blood pressure medication was given out of parameters. Staff should follow the provider's parameters. The nurses should follow the parameters and get clarification from the provider if they are unsure of an order. During an interview on 2/19/2025 at 4:17 PM with Medical Director stated, Staff are expected to follow parameters and call if they gave any questions regarding the medication order. [Resident #103's name and Resident #143 name] have not had any adverse medical issues due to her blood pressure medication administration. [Resident #143 name] medication order was a transcription error it should have been hold for systolic blood pressure greater than 130. Review of the facility policy and procedure titled Administration of Drugs with a last review date of 12/10/2024 read, Policy: Residents shall receive their medication on a timely basis and in accordance with our established policies. Procedure: .Should there be an doubt concerning the administering of medication(s), the physician's order must be verified before the medication is administered. 2.) Review of Resident #143 physician order dated 2/4/2025 read, Midodrine 5 MG (milligrams), give 1 table by mouth three times a day, hold for systolic greater than 110, hold for SBP>110 (systolic blood pressure greater than 110). Review of Resident #143's Medication Administration Record (MAR) for the month of January 2025 documented administration of Midodrine 5 MG .hold for systolic greater than 110 was given on the following dates, times and blood pressure readings on 1/3/2025 6:00 AM, Blood Pressure (BP) 135/77, 1/6/2025 10:00 PM, BP 148/87, 1/7/2025 6:00 AM, BP 164/92, 1/7/2024 10:00 PM, BP 126/88, 1/8/2025 6:00 AM, BP 134/78, 1/10/2025 6:00 AM, BP 117/68, 1/10/2025 2:00 PM, BP 111/66, 1/11/2025 6:00 AM, BP 130/69, 1/11/2025 10:00 PM, BP 130/63, 1/12/2025 6:00 AM, BP 132/75, 1/14/2025 10:00 PM, BP 112/71, 1/17/2025 10:00 PM, BP 111/ 78, 1/18/2025 6:00 AM, BP 111/78, 1/20/2025 2:00 PM, BP 111/69, 1/22/2025 2:00 PM, BP 114/64, 1/23/2025 10:00 PM, BP 99/54, not administered, 1/29/2025 2:00 PM, BP 131/70, 1/31/2025 2:00 PM, BP 131/87, and 1/31/2025 10:00 PM, BP 121/74. Review of Resident #143's Medication Administration Record (MAR) for the month of February 2025 documented administration of Midodrine 5 MG .hold for systolic greater than 110 was given on the following dates, times and blood pressure readings on 2/1/2025 6:00 AM, BP 122/74 and 2/2/2025 2:00 PM, BP 127/76. Review of Resident #143 progress note dated 1/2/2025, His past medical history is significant for . hypotension. During an interview on 2/20/2025 at 10:05 AM with the Director of Nursing stated, I would expect that if a resident has a medication order with parameters that the nurse administering the medication would administer the medication according to the parameters ordered and if the nurse needed any clarification about the order or parameters, that prior to administration they would notify the 105652 Page 6 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0684 physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105652 Page 7 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm 2)During an observation on 2/17/2025 at 10:23 AM Resident #125 was lying in bed with oxygen being administered at 3 liters per minute via nasal canula. Residents Affected - Few During an observation on 2/18/2025 at 8:12 AM Resident #125 was sitting up in bed with oxygen being administered at 3 liters via nasal cannula. During an interview on 2/18/2025 at 8:12 AM with Resident #125 stated, The nurse change it yesterday and change my tubing. I will take off my nasal cannula once in a while but I do not adjust the machine. Resident #125 physician order date 6/24/2024 read, Oxygen @ 2L/Min (at 2 liters per minute) via nasal cannula continuous inhalation every shift. During an interview on 2/18/2025 at 1:50 with Staff 125 RN stated, [Resident #125 name] Oxygen is running at 3 liters. After checking her orders Resident #125 should be at 2 liters I will adjust the concentrator rate. During an interview on 2/19/2025 at 10:44 AM with the Director of Nursing (DON) stated, Staff should monitor the flow rate and make sure it is at the appropriate rate. Review of the facility policy and procedure titled Oxygen Administration with a last review date of 12/10/2024 read, Purpose: The purpose of this procedure is to provide guidelines for oxygen administration. Procedure: .7. Turn on the oxygen. Start the flow of oxygen at the prescribed rate. Based on observation, interview and record review, the facility staff failed to ensure that oxygen was administered consistent with professional standards of practice for two (Resident #8 and Resident #125) of 6 residents reviewed for respiratory care . Findings include: 1.) During an observation on 2/17/2025 at 10:15 AM, Resident #8 was sleeping in their bed. She was observed with a nasal cannula in her nose attached to an oxygen concentrator running at 3 liters per minute (LPM). During an observation on 2/18/2025 at 12:51 PM, Resident #8 was observed sitting at the nurse's station in her wheelchair without her oxygen therapy of 2 LPM of continuous flow via a nasal cannula. During an observation on 2/19/2025 at 8:03 AM, Resident #8 was observed sleeping in her bed. She was observed with a nasal cannula in her nose attached to an oxygen concentrator running at 3 LPM. During an interview on 02/18/25 1:36 PM with the Director of Nursing, she stated that her expectations are that if a resident has an order for continuous oxygen that the resident should be kept on the prescribed flow of oxygen at all times by providing the resident with a portable oxygen cylinder. She stated that it would be expected that all departments who interact with the Resident be aware of their oxygen needs and make sure they are on oxygen as ordered. During an interview on 2/18/2025 at 1:26 PM with the Activities Assistant, she stated that Resident 105652 Page 8 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #8 was brought to the activities room for assistance with breakfast, stayed for activities after breakfast and then ate lunch with assistance, she was then brought to the nurse's station after she finished lunch. The Activities Assistant stated that during that timeframe Resident #8 was not on any oxygen flow. During an interview on 2/19/2025 at 8:03 AM with Staff D, Registered Nurse (RN) she confirmed that Resident #8's oxygen flow rate was running at 3 LPM and Resident #8's is ordered to have her oxygen flow at 2 LPM. Review of Resident #8 physician order dated 1/30/2025, reads Oxygen @ 2 L/Min (liters per minute) continuous inhalation via nasal cannula every shift for SOB (shortness of breath). 105652 Page 9 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and interview the facility failed to provide a rationale when actions were not taken for pharmacy recommendations for 3 (Resident #7, #84, and #99) of 5 residents review for unnecessary medication. Findings include: 1)Review of Resident #7 Drug Regimen Review dated 7/10/2024 read, Consultant Pharmacist Recommendations. Currently receiving Oxybutynin (Ditropan) three times daily for urinary incontinence. Oxybutynin (Ditropan) can increase risk of dizziness and falls. Per clinical record, with recent falls. Periodic discontinuation recommended to determine current need and minimize resistance to the drug. Please evaluate, consider trail taper to two times daily with eventual discontinue, if appropriate . Physician Response: Disagree with no rationale included. Review of Resident #7 Drug Regimen Review dated 11/27/2024 read, Consultant Pharmacist Recommendations. Currently with active order for Hydrocodone/APAP which can increase risk of falls with recent documented falls per clinical record. Please evaluate possible casual relationship, Consider tapering dose or implementing alternative treatment, if appropriate .Physician Response: Disagree with no rationale included. Review of Resident #7 progress note did not document a rational for recommendations on 7/10/2024 and 11/27/2024 pharmacy recommendations. During an interview on 2/20/2025 at 9:15 AM with the Administrator stated, I am not sure if the provider have to provide a reason why, I will have to check with the Director of nursing. During an interview on 2/20/2025 at 9:20 AM with the Director of Nursing stated, The provider should write a reason why they are in disagreement with the pharmacist recommendations The provider reviewed the medication but I do not see a rationale. Review of the facility policy and procedure titled Pharmacy Services-Drug Regimen Free from Unnecessary Drugs with a last review date of 12/10/2024 read, Intent: The intent of this policy is each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing . 2. Review of Resident #84 Drug Regimen Review dated 7/10/2024 read, Consultant Pharmacist Recommendations. Currently receiving Gabapentin which has potential for dizziness and drowsiness, increasing the risk of falls. Per clinical record, with recent falls. Please evaluate possible causal relationship . Consider trial taper Gabapentin to 100mg three times daily, if appropriate . Physician Response: Disagree with no rationale included. Review of Resident #84 Drug Regimen Review dated 8/13/2024 read, Consultant Pharmacist Recommendations. Currently receiving Guaifenesin LA tabs (Mucinex) without a stop date. Please evaluate current need. Consider add stop date, if appropriate . Physician Response: Disagree with no rationale included. During an interview on 2/20/2025 at 11:00 AM with the Director of Nursing stated, The provider 105652 Page 10 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some should write a reason why they are in disagreement with the pharmacist recommendations. In the progress notes he writes that the recommendations have been reviewed but does not write a rationale. Review of the facility policy and procedure titled Pharmacy Services-Drug Regimen Free from Unnecessary Drugs with a last review date of 12/10/2024 read, Intent: The intent of this policy is each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing . 3. Review of Resident #99 Drug Regimen Review dated 7/23/2024 read, Consultant Pharmacist Recommendations. Currently with order for Rivaroxaban (Xarelto) once daily in the morning with start date: 08/11/24. Recommended to be given once daily after dinner to improve absorption. Please consider switching to once daily after dinner, if appropriate . Physician Response: Disagree with no rationale included. Review of Resident #99 Drug Regimen Review dated 7/23/2024 read, Consultant Pharmacist Recommendations. Currently receiving Methotrexate Injection 50mg once a week. Please evaluate need for high dose. Consider taper to 25mg once a week, if appropriate . Physician Response: Disagree with no rationale included. Review of Resident #99 Drug Regimen Review dated 7/23/2024 read, Consultant Pharmacist Recommendations. Currently has an active order for Lorazepam prn without a specified stop date. Please note that CMS guidelines do not allow maintaining open ended orders for PRN psychotropics on medication profiles. Please evaluate and consider discontinue Lorazepam prn, if appropriate . Physician Response: Disagree with no rationale included. Review of Resident #99 Drug Regimen Review dated 10/9/2024 read, Consultant Pharmacist Recommendations. Currently receiving Duloxetine (Cymbalta) with estimated CrCl below 30ml/min. Use not recommended when CrCl is below 30ml/min due increased incidence of nausea and/or diarrhea. Please evaluate risk versus benefit and switch to alternate therapy, if appropriate . Physician Response: Disagree with no rationale included. Review of Resident #99 Drug Regimen Review dated 10/9/2024 read, Consultant Pharmacist Recommendations. Currently receiving Lorazepam which can increase risk of falls. Per clinical record, with recent falls. Please evaluate, consider tapering dose or implementing alternative treatment, if appropriate . Physician Response: Disagree with no rationale included. During an interview on 2/20/2025 at 11:00 AM with the Director of Nursing stated, The provider should write a reason why they are in disagreement with the pharmacist recommendations. In the progress notes he writes that the recommendations have been reviewed but does not write a rationale. Review of the facility policy and procedure titled Pharmacy Services-Drug Regimen Free from Unnecessary Drugs with a last review date of 12/10/2024 read, Intent: The intent of this policy is each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing . 105652 Page 11 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure residents' medications regimens were free of unnecessary antibiotic use based on adequate indications to reduce the risk of the developement of antibiotic resistant organisms for 1 (Resident #134) of 6 residents reviewed for unnecessary medications. Residents Affected - Few Findings include: Review of Resident #134's admission record documented diagnoses that included ,but were not limited to chronic kidney disease, stage 4 (severe). Review of Resident #134's nursing progress notes Change in Condition form dated 1/6/2025 at 2:24 PM, read, Other change in condition: . Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: .GU/Urine Status Evaluation: Painful urination .Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Bactrim DS one tab(tablet) po(by mouth) bid ( two times a day) x7days. Review of Resident #134's Physician orders dated 1/6/2025 at 2:29 PM read, Sulfamethoxazole-Trimethoprim Tablet 800-160 MG: Give 1 tablet by mouth every 12 hours for Prophylaxis for 7 Days. Review of Resident #134's Medication Administration Record (MAR) read, Sulfamethoxazole-Trimethoprim Tablet 800-160 MG: Give 1 tablet by mouth every 12 hours for Prophylaxis for 7 Days. The MAR documented administration of 13 doses of Sulfamethoxazole-Trimethoprim (Bactrim DS), beginning at 9:00 PM on 1/6/2025, through 9:00 PM on 1/12/2025. Review of Resident #134's progress notes dated 1/8/2025 read, Medication List: Sulfamethoxazole-Trimethoprim Tablet 800-160 MG, Give 1 tablet by mouth every 12 hours for Prophylaxis for 7 Days, 800-160MG, ACTIVE, 1/6/2025 to 1/13/2025 . Chief Complaint / Nature of Presenting Problem: Follow up for assessment and management of care with skilled nursing with lab . During an interview on 2/19/2025 at 9:30 AM, the Director of Nursing (DON) stated, If a resident has burning on urination, sometimes the doctor will treat with wide spectrum antibiotics. We should collect a UA( urinalysis). We should follow our policies for antibiotic stewardship. During an interview on 2/19/2025 at 10:21 AM, the Advanced Practice Registered Nurse (APRN) A stated, The antibiotics [for Resident #134] were prophylactic for symptoms [of a urinary tract infection]. Typically, we start antibiotics, get a urinalysis (UA) with a culture and sensitivity (C&S). I am not sure why there wasn't a UA. It's my error for not noting it. It should have been discontinued if the U/A was negative. During an interview on 2/19/2025 at 10:48 AM, the Infection Preventionist stated, If a resident displays signs and symptoms of a UTI (urinary tract infection), we notify the MD. Hopefully they will do a UA and C&S ( urine culture and sensitivity). We notify the MD (Medical Doctor) or provider and get orders with the stop date and a diagnosis for the orders. We want to get the specimen before starting antibiotics. We observe the resident, assess their abdomen, check the urine for odors, make sure they are afebrile, check for alterations in mental status, and signs and symptoms of infection. We try to educate the MD to not give broad spectrum antibiotics and not get labs (a urine C&S). We remind the MD if the resident is asymptomatic to possibly stop the antibiotics. We did not follow our 105652 Page 12 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0757 antibiotic stewardship policy. The antibiotic should have been stopped. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/19/2025 at 11:10 AM, the Medical Director stated, [For a resident with burning on urination] I give antibiotics first and then get the UA. If the UA is negative, then we will stop the antibiotics. Waiting on the labs can make if difficult because of the delay and the patient can get sicker. Sometimes patients refuse labs, and then I can go in and cancel the order. I actually ordered the antibiotics [for Resident #134] and did not order labs. Residents Affected - Few Review of the facility's policy, last reviewed on 12/10/2024, titled Antibiotic Stewardship read, Policy Statement: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Policy Interpretation and Implementation: . 4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: a. Drug name; b. Dose; c. frequency of administration; d. duration of treatment: 1) start and stop date; or 2) number of days of therapy e. route of administration; and f. indications of use . 10. When antibiotics are prescribed over the phone, the primary care practitioner will assess the resident within 72 hours of the telephone order. 105652 Page 13 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional standards of practice when unsecured medications were observed in resident rooms for 1 out of 4 units reviewed for unattended medication. Finding include: 1)During an observation on 2/17/2025 at 10:17 AM Resident # 65 was lying in bed and on top of her bedside table there was a bottle of Fluticasone Propionate Lotion 0.05%. (photographic evidence obtained) During an interview on 2/17/2025 at 10:17 AM Resident #65 stated, I have the nurse apply the lotion to my back when it is itchy. Review of Resident #65 physician orders did not reveal a medication self-administration order. Review of Resident #65 care plan did not document a focus for medication self-administration. During an observation on 2/17/2025 at 10:21 AM Resident #80 was sitting in a wheelchair in her room. There was a circular white tablet in a plastic medication cup on top of the bedside table. (photographic evidence obtained) During an interview on 2/17/2025 at 10:21 AM Resident #80 stated, The nurse brought me a tums. I had heart burn and upset stomach. Review of Resident #80 physician orders did not reveal a medication self-administration order. Review of Resident #80 care plan did not document a focus for medication self-administration. During an observation on 2/17/2025 at 10:41 AM Resident # 4 was sitting in his room. On top of the residents bedside table there were 4 circular white tablets. (photographic evidence obtained.) During an interview on 2/17/2025 at 10:41 AM Resident #4 stated, The nurse just gave me these pills. They are Tylenol and the other is for my heart. Review of Resident #4 physician orders did not reveal a medication self-administration order. Review of Resident #4 care plan did not document a focus for medication self-admisnitration. During an interview on 2/19/2025 at 10:58 AM the Director of Nursing (DON) stated, We usually do a self-administration assessment to determine if the residents are able to self-administer medication. I don't see that (self administration assessment) completed for [Resident #80's name, Resident #65's name, and Resident #4's name]. The nursing staff should stay with the resident to make sure that they take the medication. Medication should not be left unattended in the resident's room. 105652 Page 14 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0761 Level of Harm - Minimal harm or potential for actual harm Review of the policy and procedure titled Medication storage with a last review date of 12/10/2024 read, Policy: Medication will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with FL [Florida] Department of Health guidelines. Procedure: A. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by the facility policy. Residents Affected - Few 105652 Page 15 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 3) During an observation on 02/17/25 at 10:03 AM Resident #47 was lying in bed with oxygen being administered at three liters per minute, a nebulizer mask was on top of the drawer with no bag. Residents Affected - Few During an observation on 2/18/2025 at 8:15 AM Resident #47 was lying in bed the nebulizer mask was on top of the drawer without a bag. Review of Resident #47 physician order dated 8/22/2024 read, Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) (2.5 milligram/3 milliliter)0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath Review of Resident #47 physician order dated 11/7/2024 read, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally via nebulizer every 6 hours as needed for SOB (shortness of breath). During an interview on 2/18/2025 at 1:52 PM Staff B Registered Nurse (RN) stated, [Resident #47 name] nebulizer mask should be stored in a bag when not in use. The bag should be dated. During an interview 2/19/2025 at 10:48 AM the Director of Nursing stated Nebulizer masks and oxygen tubing should be bagged when not in use. Review of the policy and procedure titled Respiratory Therapy Equipment with a last review date of 12/10/2024 read, Purpose: The purpose of this procedure is to provide guidelines to help prevent nosocomial infections associated with respiratory therapy equipment, including ventilators, and to prevent transmission of infections to resident and staff .Procedure: .5. Keep oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infection by failing to perform hand hygiene during medication administration for 4 (Residents #96 and #407) of 6 residents observed for medication administration, and failed to follow acceptable standards of care for storage of respiratory care equipment for 2 ( Resident #47 and Resident #143) of 6 residents reviewed for Respiratory care. Findings include: During an observation on 2/19/25 at 8:25 AM, Staff A, Registered Nurse (RN) was observed administering a medication intravenously to Resident #96 without performing hand hygiene before donning gloves and administering the medication or after removing her gown and gloves. Staff A, RN was observed returning to the medication cart to administer another residents medications. During an interview on 2/19/25 at 8:34 AM, Staff A, RN stated, I didn't wash my hands. During an observation on 2/19/25 at 8:37 AM, Staff C, Licensed Practical Nurse (LPN) was observed preparing medications without performing hand hygiene, entering the residents room and administering oral medications to Resident #407 without performing hand hygiene. Staff C, LPN returned to the medication cart and began preparing medications for another resident. 105652 Page 16 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0880 During an interview on 2/19/25 at 8:40 AM, Staff C, LPN stated, I didn't use the hand foam. Level of Harm - Minimal harm or potential for actual harm Review of the policy and procedure, last updated on 12/10/24, titled Handwahing / Hand Hygiene, read, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation . 2. All presonnel shall follow handwahing/hand hygiene processes to prevent the spread of infections to other personnel, residents, and visitors . 5. Use an alcohol-based hand-rub containing at least 62% alcohol; or alternatively, soap (anti-microbial or non-antimicrobial) and water for the following situations . c. Before preparing or handling medications . 6. Hand hygiene is the last step after removing and disposing of personal protective equipment. Residents Affected - Few 2.) During an observation on 2/17/2025 at 10:04 AM, Resident #143's nebulizer mask was observed on the bedside table without a bag. (Photographic Evidence Obtained) During an observation on 2/18/2025 at 12:51 PM, Resident #8's nasal cannula was observed laying on the floor in her room. The oxygen concentrator was not on at the time of the observation and the Resident was not in the room. (Photographic Evidence Obtained) During an interview on 2/18/2025 at 12:51 PM, Staff D, Registered Nurse (RN), stated, A residents' nasal cannula should be stored in a bag when not in use. During an interview on 2/18/2025 at 1:36 PM the Director of Nursing, stated, Respiratory equipment including nebulizer mask should be stored in a bag when not in use. If a resident has an oxygen order to be used as needed, when the resident does not have the cannula on, it would also be stored in a bag. Review of Resident #143's physician order dated 8/27/2024, reads Budesonide inhalation suspension 0.5 milligram (MG)/2 milliliters (ML), 1 puff inhale orally two times a day for wheezing. Review of Resident #143's physician order dated 8/27/2024, reads Albuterol Sulfate hydrofluoroalkane (HFA) inhalation aerosol solution 108 (90 Base) micrograms (MCG)/ Albuterol Sulfate (ACT), 2 puff inhale orally every 4 hours as needed for wheezing. 105652 Page 17 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to implement its antibiotic stewardship protocol when it failed to monitor the use of antibiotics to reduce the risk of development of antibiotic resistance for 1 (Resident # 134) of 3 residents reviewed for urinary tract infections. Residents Affected - Few Findings include: Review of Resident #134's admission record documented diagnoses that included ,but were not limited to chronic kidney disease, stage 4 (severe). Review of Resident #134's nursing progress notes Change in Condition form dated 1/6/2025 at 2:24 PM, read, Other change in condition: . Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: .GU/Urine Status Evaluation: Painful urination .Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Bactrim DS one tab(tablet) po(by mouth) bid ( two times a day) x7days. Review of Resident #134's Physician orders dated 1/6/2025 at 2:29 PM read, Sulfamethoxazole-Trimethoprim Tablet 800-160 MG: Give 1 tablet by mouth every 12 hours for Prophylaxis for 7 Days. Review of Resident #134's Medication Administration Record (MAR) read, Sulfamethoxazole-Trimethoprim Tablet 800-160 MG: Give 1 tablet by mouth every 12 hours for Prophylaxis for 7 Days. The MAR documented administration of 13 doses of Sulfamethoxazole-Trimethoprim (Bactrim DS), beginning at 9:00 PM on 1/6/2025, through 9:00 PM on 1/12/2025. Review of Resident #134's progress notes dated 1/8/2025 read, Medication List: Sulfamethoxazole-Trimethoprim Tablet 800-160 MG, Give 1 tablet by mouth every 12 hours for Prophylaxis for 7 Days, 800-160MG, ACTIVE, 1/6/2025 to 1/13/2025 . Chief Complaint / Nature of Presenting Problem: Follow up for assessment and management of care with skilled nursing with lab . During an interview on 2/19/2025 at 9:30 AM, the Director of Nursing (DON) stated, If a resident has burning on urination, sometimes the doctor will treat with wide spectrum antibiotics. We should collect a UA( urinalysis). We should follow our policies for antibiotic stewardship. During an interview on 2/19/2025 at 10:21 AM, the Advanced Practice Registered Nurse (APRN) A stated, The antibiotics [for Resident #134] were prophylactic for symptoms [of a urinary tract infection]. Typically, we start antibiotics, get a urinalysis (UA) with a culture and sensitivity (C&S). I am not sure why there wasn't a UA. It's my error for not noting it. It should have been discontinued if the U/A was negative. During an interview on 2/19/2025 at 10:48 AM, the Infection Preventionist stated, If a resident displays signs and symptoms of a UTI (urinary tract infection), we notify the MD. Hopefully they will do a UA and C&S ( urine culture and sensitivity). We notify the MD (Medical Doctor) or provider and get orders with the stop date and a diagnosis for the orders. We want to get the specimen before starting antibiotics. We observe the resident, assess their abdomen, check the urine for odors, make sure they are afebrile, check for alterations in mental status, and signs and symptoms of infection. We try to educate the MD to not give broad spectrum antibiotics and not get labs (a urine C&S). We remind the MD if the resident is asymptomatic to possibly stop the antibiotics. We did not follow our antibiotic stewardship policy. The antibiotic should have been stopped. 105652 Page 18 of 19 105652 02/20/2025 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0881 Level of Harm - Minimal harm or potential for actual harm During an interview on 2/19/2025 at 11:10 AM, the Medical Director stated, [For a resident with burning on urination] I give antibiotics first and then get the UA. If the UA is negative, then we will stop the antibiotics. Waiting on the labs can make if difficult because of the delay and the patient can get sicker. Sometimes patients refuse labs, and then I can go in and cancel the order. I actually ordered the antibiotics [for Resident #134] and did not order labs. Residents Affected - Few Review of the facility's policy, last reviewed on 12/10/2024, titled Antibiotic Stewardship read, Policy Statement: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Policy Interpretation and Implementation: . 4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: a. Drug name; b. Dose; c. frequency of administration; d. duration of treatment: 1) start and stop date; or 2) number of days of therapy e. route of administration; and f. indications of use. Review of the facility's Clinical Protocol, last reviewed on 12/10/2024, titled Urinary Tract Infection/Bacteriuria read, Assessment and Recognition: . 2. The staff and practitioners will identify individuals with possible signs and symptoms of a urinary tract infection (UTI) .b. Nurses should observe, document, and report signs and symptoms (for example, fever or hematuria (blood in the urine)) in detail and avoid premature diagnostic conclusions .e . The presence of pyuria or a positive leukocyte esterase test alone are not enough to prove that the individual has a UTI, but the absence of pyuria or a negative leukocyte esterase test is fairly strong evidence that a UTI is not present. Cause Identification: 1. The physician will help nursing staff interpret any signs, symptoms, and lab test results. Diagnosis must be based on the entire picture and not just one or several findings in isolation. a. Before diagnosing a UTI or urosepsis (a serious infection that occurs when a UTI spreads to the bloodstream) and ordering antibiotics, the physician should consider a resident's overall picture including specific evidence that helps confirm or refute the diagnosis of a UTI (as described above). 3. Because nonspecific or systemic symptoms can be due to diverse factors either instead of or along with a UTI, the staff and practitioner will also consider additional or alternative causes regardless of whether bacteriuria or urinary symptom is present . Treatment/Management: 1. The physician will order appropriate treatment for verified or suspected UTIs and/or urosepsis based on a pertinent assessment. a. Empirical treatment should be based on a documented description of an individual's symptoms and on consideration of relevant test results, co-existing illnesses and conditions, and pertinent risk factors . 3. The physician should consider stopping antibiotics or switching parenteral to oral antibiotics in individuals with uncomplicated UTIs who have been afebrile and asymptomatic for at least 48 hours. Monitoring: 1. The physician and nursing staff will review the status of individuals who are being treated for a UTI and adjust treatment accordingly. a. Decisions should be made primarily on the basis of clinical signs and symptoms. The goal of treatment in most cases is to control signs and symptoms of infection, not to eliminate bacteriuria . 105652 Page 19 of 19